Background: and Purpose We aimed to develop a model predicting early recanalization after intravenous tissue plasminogen activator (t-PA) treatment in large-vessel occlusion. Methods: Using data from two different multicenter prospective cohorts, we determined the factors associated with early recanalization immediately after t-PA in stroke patients with large-vessel occlusion, and developed and validated a prediction model for early recanalization. Clot volume was semiautomatically measured on thin-section computed tomography using software, and the degree of collaterals was determined using the Tan score. Follow-up angiographic studies were performed immediately after t-PA treatment to assess early recanalization. Results: Early recanalization, assessed 61.0±44.7 minutes after t-PA bolus, was achieved in 15.5% (15/97) in the derivation cohort and in 10.5% (8/76) in the validation cohort. Clot volume (odds ratio [OR], 0.979; 95% confidence interval [CI], 0.961 to 0.997; P=0.020) and good collaterals (OR, 6.129; 95% CI, 1.592 to 23.594; P=0.008) were significant factors associated with early recanalization. The area under the curve (AUC) of the model including clot volume was 0.819 (95% CI, 0.720 to 0.917) and 0.842 (95% CI, 0.746 to 0.938) in the derivation and validation cohorts, respectively. The AUC improved when good collaterals were added (derivation cohort: AUC, 0.876; 95% CI, 0.802 to 0.950; P=0.164; validation cohort: AUC, 0.949; 95% CI, 0.886 to 1.000; P=0.036). The integrated discrimination improvement also showed significantly improved prediction (0.097; 95% CI, 0.009 to 0.185; P=0.032). Conclusions The model using clot volume and collaterals predicted early recanalization after intravenous t-PA and had a high performance. This model may aid in determining the recanalization treatment strategy in stroke patients with large-vessel occlusion.

Background and Objectives: Prior studies have shown that stroke patients treated with percutaneous left atrial appendage occlusion (LAAO) for non-valvular atrial fibrillation (NVAF) experience better outcomes than similar patients treated with warfarin. We investigated the impact of percutaneous left atrial appendage closure on post-stroke neurological outcomes in NVAF patients, compared with non-vitamin K antagonist oral anticoagulant (NOAC) therapy. Methods: Medical records for 1,427 patients in multiple registries and for 1,792 consecutive patients at 6 Korean hospitals were reviewed with respect to LAAO or NOAC treatment.Stroke severity in patients who experienced ischemic stroke or transient ischemic attack after either treatment was assessed with modified Rankin Scale (mRS) scoring at hospital discharge and at 3 and 12 months post-stroke. Results: mRS scores were significantly lower in LAAO patients at 3 (p<0.01) and 12 months (p<0.01) post-stroke, despite no significant differences in scores before the ischemic cerebrovascular event (p=0.22). The occurrences of disabling ischemic stroke in the LAAO and NOAC groups were 36.7% and 44.2% at discharge (p=0.47), 23.3% and 44.2% at 3 months post-stroke (p=0.04), and 13.3% and 43.0% at 12 months post-stroke (p=0.01), respectively.Recovery rates for disabling ischemic stroke at discharge to 12 months post-stroke were significantly higher for LAAO patients (50.0%) than for NOAC patients (5.6%) (p<0.01). Conclusions Percutaneous LAAO was associated with more favorable neurological outcomes after ischemic cerebrovascular event than NOAC treatment.

Background: and Purpose We aimed to develop a model predicting early recanalization after intravenous tissue plasminogen activator (t-PA) treatment in large-vessel occlusion. Methods: Using data from two different multicenter prospective cohorts, we determined the factors associated with early recanalization immediately after t-PA in stroke patients with large-vessel occlusion, and developed and validated a prediction model for early recanalization. Clot volume was semiautomatically measured on thin-section computed tomography using software, and the degree of collaterals was determined using the Tan score. Follow-up angiographic studies were performed immediately after t-PA treatment to assess early recanalization. Results: Early recanalization, assessed 61.0±44.7 minutes after t-PA bolus, was achieved in 15.5% (15/97) in the derivation cohort and in 10.5% (8/76) in the validation cohort. Clot volume (odds ratio [OR], 0.979; 95% confidence interval [CI], 0.961 to 0.997; P=0.020) and good collaterals (OR, 6.129; 95% CI, 1.592 to 23.594; P=0.008) were significant factors associated with early recanalization. The area under the curve (AUC) of the model including clot volume was 0.819 (95% CI, 0.720 to 0.917) and 0.842 (95% CI, 0.746 to 0.938) in the derivation and validation cohorts, respectively. The AUC improved when good collaterals were added (derivation cohort: AUC, 0.876; 95% CI, 0.802 to 0.950; P=0.164; validation cohort: AUC, 0.949; 95% CI, 0.886 to 1.000; P=0.036). The integrated discrimination improvement also showed significantly improved prediction (0.097; 95% CI, 0.009 to 0.185; P=0.032). Conclusions The model using clot volume and collaterals predicted early recanalization after intravenous t-PA and had a high performance. This model may aid in determining the recanalization treatment strategy in stroke patients with large-vessel occlusion.

Background and Objectives: Prior studies have shown that stroke patients treated with percutaneous left atrial appendage occlusion (LAAO) for non-valvular atrial fibrillation (NVAF) experience better outcomes than similar patients treated with warfarin. We investigated the impact of percutaneous left atrial appendage closure on post-stroke neurological outcomes in NVAF patients, compared with non-vitamin K antagonist oral anticoagulant (NOAC) therapy. Methods: Medical records for 1,427 patients in multiple registries and for 1,792 consecutive patients at 6 Korean hospitals were reviewed with respect to LAAO or NOAC treatment.Stroke severity in patients who experienced ischemic stroke or transient ischemic attack after either treatment was assessed with modified Rankin Scale (mRS) scoring at hospital discharge and at 3 and 12 months post-stroke. Results: mRS scores were significantly lower in LAAO patients at 3 (p<0.01) and 12 months (p<0.01) post-stroke, despite no significant differences in scores before the ischemic cerebrovascular event (p=0.22). The occurrences of disabling ischemic stroke in the LAAO and NOAC groups were 36.7% and 44.2% at discharge (p=0.47), 23.3% and 44.2% at 3 months post-stroke (p=0.04), and 13.3% and 43.0% at 12 months post-stroke (p=0.01), respectively.Recovery rates for disabling ischemic stroke at discharge to 12 months post-stroke were significantly higher for LAAO patients (50.0%) than for NOAC patients (5.6%) (p<0.01). Conclusions Percutaneous LAAO was associated with more favorable neurological outcomes after ischemic cerebrovascular event than NOAC treatment.

BACKGROUND/AIMS: Advanced age is a known risk factor of poor outcomes for colitis, including Clostridium difficile infection (CDI). The present study compares the clinical outcomes of young and old patients hospitalized for CDI. METHODS: The clinical records of patients admitted from January 2007 to December 2013 with a diagnosis of CDI were analyzed. Patient baseline characteristics, clinical courses, and outcomes were compared with respect to age using a cut-off 65 years. RESULTS: Of the 241,391 inpatients registered during the study period, 225 (0.1%) with a diagnosis of CDI were included in the study. The mean patient age was 67.7 years. Seventy-two patients (32.0%) were younger than 65 years and 153 patients (68.0%) were 65 years old or more. The male to female ratio in the younger group was 0.8, and 0.58 in the older group. All 225 study subjects had watery diarrhea; six patients (8.3%) complained of bloody diarrhea in the young group and 21 patients (13.7%) in the old group (p=0.246). Right colon involvement was more common in the old group (23.5% vs. 42.7%, p=0.033). Furthermore, leukocytosis (41.7% vs. 67.3%, p=0.000), a CDI score of > or =3 points (77.8% vs. 89.5%, p=0.018), and hypoalbuminemia (58.3% vs. 76.5%, p=0.005) were more common in the old group. Failure to first line treatment was more common in the old group (17 [23.6%] vs. 58 [37.9%], p=0.034). CONCLUSIONS: Severe colitis and failure to first line treatment were significantly more common in patients age 65 years or more. More aggressive initial treatment should be considered for older CDI patients.
Adult ; Age Factors ; Aged ; Aged, 80 and over ; Albuminuria/etiology ; Anti-Bacterial Agents/therapeutic use ; Clostridium Infections/complications/*diagnosis/drug therapy ; Diarrhea/complications ; Female ; Hospitalization ; Humans ; Leukocytosis/etiology ; Male ; Middle Aged ; Retrospective Studies ; Risk Factors ; Severity of Illness Index

BACKGROUND AND OBJECTIVES: Success rates of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have recently been reported to range from 80% to 90%. A better understanding of the pathologic characteristics of the CTO lesion may helpful to improving CTO PCI success rates. We evaluated the CTO lesion in patients with stable angina (SA) by virtual histology-intravascular ultrasound (VH-IVUS). SUBJECTS AND METHODS: The study population consisted of 149 consecutive patients with SA underwent VH-IVUS examination. We analyzed demographic and VH-IVUS findings in 22 CTO patients (17 males; mean, 62.3 years old) compared with 127 non-CTO patients (82 males; mean, 61.3 years old). RESULTS: A significantly lower ejection fraction (57.6+/-13.0% vs. 65.4+/-8.8%, p=0.007) was detected in the CTO group compared with the non-CTO group. Reference vessel lumen area of the proximal and distal segment was significantly less in CTO group than in non-CTO group. The lesion length of the CTO group was significantly longer than those of the non-CTO group (24.4+/-9.6 mm vs. 17.2+/-7.4 mm, p<0.001). Total atheroma volume (224+/-159 mm3 vs. 143+/-86 mm3, p=0.006) and percent atheroma volume (63.2+/-9.6% vs. 55.8+/-8.5%, p=0.011) of the CTO group were also significantly greater than those of non-CTO group. However, the lesion length adjusted plaque composition of the CTO group was not significantly different compared with that of the non-CTO group. CONCLUSION: CTO lesions had a longer lesion length and greater plaque burden than the non-CTO lesion in patients with SA. However, lesion length adjusted plaque composition showed similar between the two groups. These results support that plaque characteristics of CTO lesions are similar to non-CTO lesions in patients with SA.
Angina Pectoris ; Angina, Stable ; Humans ; Male ; Percutaneous Coronary Intervention ; Plaque, Atherosclerotic ; Ultrasonography* ; Ultrasonography, Interventional

The aims of this study were to review the clinicopathological characteristics of diminutive (≤ 5 mm) and small polyps (> 5 mm but < 10 mm) and to evaluate the risk factors of advanced adenoma for polyps of diameter < 10 mm in the colon. The medical records of 4,711 patients who underwent first colonoscopy at outpatient clinics or health promotion center were reviewed retrospectively. We analyzed the presence and risk factors of advanced adenoma, which was defined as a villous or tubulovillous polyp, high-grade dysplasia or intramucosal carcinoma histologically. Total 5,058 polyps were detected in the 4,711 patients, and 93.0% (4,704/5,058) polyps were < 10 mm in size. Among them, advanced adenoma was noted in 0.6% (28/4,704) with a villous component in 19, high-grade dysplasia in 3, and adenocarcinoma in 6. Advanced and non-advanced adenomas differed significantly in age group, gender, and polyp size. Multivariate analysis showed that an advanced age (> 65 years), a male gender, and a polyp size of > 5 mm were risk factors of advanced adenoma. The incidence of advanced adenoma in polyps of < 10 mm was 0.6%. Polyp size, male gender, and age of > 65 years are independent risk factors of advanced adenoma.
Adenocarcinoma ; Adenoma* ; Ambulatory Care Facilities ; Colon ; Colonoscopy ; Health Promotion ; Humans ; Incidence ; Male ; Medical Records ; Multivariate Analysis ; Polyps* ; Retrospective Studies ; Risk Factors*

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is generally performed with the use of inverse triangulation. In this study, we performed 3-channel or 4-channel SILC without the use of inverse triangulation. We evaluated the adequacy and feasibility of SILC using our surgical method. METHODS: We retrospectively reviewed our series of 309 SILCs performed between March 2014 and February 2015. RESULTS: Among 309 SILCs, male were 148 and female were 161 patients, mean age was 48.7 +/- 15.3 years old and mean body mass index was 24.8 +/- 3.8 kg/m2. Forty patients had previously undergone abdominal surgery including 6 cases of upper abdominal surgery. SILC after percutaneous transhepatic gallbladder (GB) drainage was completed in 8.7% of cases. There were 10 cases of emergency SILC. SILC was performed for noncomplicated GB including symptomatic GB stone and polyp in 66.7% of cases, acute cholecystitis in 33.3%. Overall, 96.8% of procedures were successfully completed without additional port. The reason for addition of an extra port or open conversion included technical difficulties due to severe adhesion and bleeding. The mean operating time was 60.7 +/- 22.3 minutes. The overall complication rate was 4.8%: 9 patients of wound seroma, 1 case of bile leakage from GB bed, 4 cases of intra-abdominal abscess or fluid collection, and 1 case of incisional hernia were developed. There was no case of common bile duct injury. CONCLUSION: Our surgical method of SILC without the use of inverse triangulation is safe, feasible and effective technique.
Abdominal Abscess ; Bile ; Body Mass Index ; Cholecystectomy, Laparoscopic* ; Cholecystitis, Acute ; Common Bile Duct ; Drainage ; Emergencies ; Female ; Gallbladder ; Hemorrhage ; Hernia ; Humans ; Laparoscopy ; Male ; Polyps ; Retrospective Studies ; Seroma ; Wounds and Injuries

BACKGROUND AND OBJECTIVES: Both carotid intima-media thickness (CIMT) and carotid plaque are important factors in the primary prevention of cardiac disease. However, it is unclear which one is more important for prognosis, especially in patients with coronary artery disease (CAD). SUBJECTS AND METHODS: In total, 1426 consecutive CAD patients, proven by angiography, were followed-up for a mean of 85 months. The study population was divided into four groups depending on the CIMT (> or =0.83 mm, >95 percentile in Korea) and the presence or absence of carotid plaque. RESULTS: Patients with carotid plaque and thick CIMT (n=237, 16.6%) had a higher prevalence of hypertension, diabetes mellitus, and dyslipidemia than those had plaque and thin CIMT (n=213, 14.9%), those without plaque and thick CIMT (n=265, 18.6%) and those without plaque and thin CIMT (n=711, 49.9%). The patients with carotid plaque and thick CIMT group had a higher cardiac mortality rate (20.7% vs. 13.1%, 9.4% and 3.9%, respectively, p<0.001) and higher major adverse cardiovascular events (MACE) including death, acute myocardial infarction, and stroke (27.8% vs. 18.8%, 15.5% and 9.3%, respectively, p<0.001) than any other groups. Multivariate Cox regression analysis showed that the presence of carotid plaque with thick CIMT had the highest hazard ratio (HR) compared to other groups (HR 2.23 vs. 1.81, 2.01) for cardiac mortality. Also, carotid plaque had a higher HR than CIMT for mortality (HR 1.56 vs. 1.37) and MACE (HR 1.54 vs. 1.36) in the total study population. CONCLUSION: Carotid plaque is a more important prognostic factor than CIMT in patients with CAD, and adding a thick CIMT to carotid plaque increases the prognostic power for cardiac events.
Angiography ; Carotid Intima-Media Thickness ; Carotid Stenosis ; Coronary Artery Disease* ; Diabetes Mellitus ; Dyslipidemias ; Follow-Up Studies* ; Heart Diseases ; Humans ; Hypertension ; Mortality ; Myocardial Infarction ; Prevalence ; Primary Prevention ; Prognosis ; Stroke ; Ultrasonography*

A bezoar is a mass formed by the accumulation of digested food. A biliary bezoar, namely a bezoar formed in the bile duct, is rare, which occurs mostly in patients who formerly underwent cholecystectomy. It appears that incompetent sphincter produces occasional reverse flow of foreign bodies including undigested food from the alimentary canal into the bile tract. Surgical treatment is used for huge biliary bezoar which is too huge to be removed by nonsurgical treatment. Extracorporeal shock wave lithotripsy (ESWL) is mostly used to fragment renal or urinary calculi, but may be sparingly used against biliary calculi. This is to report the rare case of a patient with biliary bezoar who formerly underwent open cholecystectomy and choledocoduodenostomy. The patient's huge biliary bezoar was removed by ESWL and the successive execution of endoscopic retrograde cholangio pancreatography (ERCP). ESWL is expected to be a comparatively safe and convenient solution to huge biliary bezoars.
Bezoars* ; Bile ; Bile Ducts ; Cholecystectomy ; Foreign Bodies ; Gallstones ; Humans ; Lithotripsy ; Shock ; Urinary Calculi